Talking Through the Clutter

When multiple physicians treat a patient, the potential for error increases not from any particular action, but from a missed communication between them.

The patient, who had crashed her automobile the evening before, presents to the emergency room at 5:30 a.m., with complaints of pain in her face, chest, abdomen, knees, and right ankle. ER Dr. A’s exam revealed facial bruising, pupils equal and reactive to light, normal upper extremity movement, and seatbelt contusion over the chest and upper right abdomen, with tenderness. Heart sounds were normal, pelvis was stable, and knees were bilaterally bruised and swollen. The patient’s right ankle was bruised, swollen, and tender to palpation.

ER Dr. A ordered a full range of tests, including CT scan of the abdomen and pelvis and X-rays of the chest, cervical spine, face, right ankle, and knees. At 7:00 a.m., care was endorsed to ER Dr. B. Approximately 30 minutes later, ER Dr. B contacted Dr. C, the general surgeon on call, with news of chest and abdominal contusions secondary to seatbelt injury, free fluid in the pelvis, and tender abdominal examination. Dr. C agreed, via telephone, to admit the patient.

ER Dr. B’s admitting diagnosis was “traumatic intra-abdominal hemorrhage with liver laceration; evaluation of motor vehicle accident; and multiple musculoskeletal injuries to knees, face, and ankle.” Dr. C arrived at the hospital at 9:00 a.m., approximately 35 minutes after the X-rays were taken.

After a CT scan of the thorax came back negative for aortic injury, Dr. C moved the patient from the ICU on her second day and treated the liver laceration non-surgically. During the patient’s four-day hospitalization, nursing notes refer to continuing complaints of right ankle pain and swelling, relieved by ice packs. Dr. C did not treat the ankle, other than ordering some physical therapy for the lower extremities, and his discharge note made no reference to ankle problems. Dr. C did recommend that the patient visit his office in one week for follow-up.

In fact, the radiologist’s report, dictated at 1:30 p.m. and transcribed at 5:00 p.m., on the patient’s first day, described an oblique, non-displaced fracture of the calcaneus, right ankle. The report became part of the hospital’s written and electronic record, but the radiologist did not call any of the physicians with this finding.

Following discharge, the patient did not follow up with Dr. C, but instead saw an acupuncturist and then a podiatrist. The podiatrist put the foot in a cast for five weeks and then ordered an MRI – which revealed the now-six-month old calcaneus fracture and a complete tear of the anterior talofibular ligament.

A judicial arbitration found against Dr. C, whose defense was that though he knew the musculoskeletal X-rays had been ordered, he had assumed, under hospital protocol, that the ER physician who ordered the films would have contacted him or an orthopedic surgeon with an abnormal result.

By all accounts, this patient was thoroughly evaluated and worked up for an array of potentially dangerous injuries. But for the physicians’ failure to communicate on one of those injuries, a timely treatment opportunity was lost.

Gordon Ownby, CAP-MPT’s general counsel, can be reached at gownby@cap-mpt.com.